Inaccurate MDS Coding for Use of Alarms
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for two sampled residents. For one resident with diagnoses including anxiety disorder, metabolic encephalopathy, major depressive disorder, and dementia, the care plan indicated the use of a clip alarm as an intervention for fall risk. However, the resident's Significant Change MDS did not reflect the use of the clip alarm, despite documentation and staff acknowledgment that the device had been in use since the previous year. Another resident, observed multiple times with a personal tabs alarm in place, also had a care plan intervention for a clip alarm due to fall risk. Despite these observations and care plan documentation, the resident's Significant Change MDS was coded to indicate no chair alarm was used. The MDS Coordinator confirmed that the MDS assessments for both residents were inaccurately coded and did not reflect the residents' actual status during the observation period.